Provider Demographics
NPI:1316828908
Name:QUILLEN, JOHN WALTON (LADAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTON
Last Name:QUILLEN
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E BROADWAY AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5755
Mailing Address - Country:US
Mailing Address - Phone:865-579-4443
Mailing Address - Fax:
Practice Address - Street 1:200 E BROADWAY AVE STE 305A
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5780
Practice Address - Country:US
Practice Address - Phone:865-579-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00897101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)